Citation Nr: 1750134 Decision Date: 11/03/17 Archive Date: 11/13/17 DOCKET NO. 13-36 367 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to a rating in excess of 20 percent for diabetes mellitus, type II. 2. Entitlement to an increased initial rating for tremor and bradykinesia of the right upper extremity associated with Parkinson's disease. 3. Entitlement to an effective date prior to January 16, 2008, for grant of a separate compensable rating for tremor and bradykinesia of the left upper extremity associated with Parkinson's. 4. Entitlement to an effective date prior to October 21, 2009, for grant of a separate compensable rating for tremor and bradykinesia of the right lower extremity with balance impairment associated with Parkinson's. 5. Entitlement to an effective date prior to October 21, 2009, for grant of a separate compensable rating for tremor and bradykinesia left lower extremity with balance impairment associated with Parkinson's. 6. Entitlement to an effective date prior to October 21, 2009, for grant of a separate rating for speech changes, twelfth (hypoglossal) cranial nerve associated with Parkinson's. 7. Entitlement to an effective date prior to October 21, 2009, for grant of a separate rating for loss of automatic movements, fifth (trigeminal) cranial nerve associated with Parkinson's. 8. Entitlement to an effective date prior to October 21, 2009, for grant of a separate rating for loss of the sense of smell associated with Parkinson's. 9. Entitlement to an effective date prior to October 21, 2009, for grant of a separate rating for stooped posture, eleventh (spinal accessory, external branch cranial nerve) associated with Parkinson's. 10. Entitlement to an effective date prior to January 16, 2008, for grant of a separate compensable rating for dyskinesia, head and neck (previously rated as balance impairment associated with Parkinson's). 11. Entitlement to a rating in excess of 10 percent for dyskinesia, head and neck associated with Parkinson's. 12. Entitlement to special monthly compensation (SMC) on the basis of housebound status. ATTORNEY FOR THE BOARD N. Rippel, Counsel INTRODUCTION The Veteran had active service in the U.S. Marine Corps from July 1969 to October 1970 including service in the Republic of Vietnam. He was awarded the Combat Action Ribbon. The Veteran died in May 2014; the Appellant is his surviving spouse. These matters come before the Board of Veterans' Appeals (Board) on appeal from October 2012, December 2012, and January 2014 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. Unfortunately, the Veteran died during the pendency of the appeal. In an August 2014 decision, the Board dismissed the Veteran's appeal. The Appellant timely appealed that dismissal to the Court of Appeals for Veterans Claims (Court). During the pendency of the Court appeal, the Board reactivated the appeal, reassigned the original docket number, and in a May 2015 VA memorandum the Veteran's spouse was recognized as the substituted claimant. As the relief sought had already been granted, the Court dismissed the Appellant's appeal as moot in a June 2015 order. The Board remanded these matters in a February 2016 decision. In that decision, the Board re-characterized the Appellant's claims for earlier effective dates for service connection for various Parkinson's symptoms, as claims for earlier effective dates for separate compensable ratings. In a June 2016 rating decision, the RO granted an effective date of January 16, 2008, for service connection for dyskinesias, head and neck (previously rated as balance impairment (ninth (glossopharyngeal) cranial nerve)). The following brief procedural history of was provided by the Board in the remand, and will be reiterated, to explain the Board's actions in that remand. A March 2011 rating decision granted service connection for Parkinson's disease with residuals to include tremors in all extremities with bradykinesia, rigidity, hypokinetic dysarthria, and micrographia, effective October 15, 2001, and assigned a 30 percent rating under 38 C.F.R. § 4.124a, Diagnostic Code 8804 (2016). Under Diagnostic Code 8004, "a minimum 30 percent rating is for application when there are "ascertainable residuals" of paralysis agitans" or Parkinson's disease. 38 C.F.R. § 4.124a, Diagnostic Code 8004 (2016). However, VA is also required to consider whether any residuals may be otherwise rated under a separate diagnostic code. If there are identifiable residuals that can be rated under a separate diagnostic code, and the combined disability rating resulting from these residuals exceeds 30 percent, then these separate ratings will be assigned in place of the minimum rating assigned under Diagnostic Code 8004. See also VA Adjudication Procedures Manual M21-1, Part III.iv.4.G.25 (June 23, 2013). On March 16, 2011, VA received VA Form 21-8940, which the AOJ construed as an increased rating claim for, inter alia, Parkinson's. In association with that claim, new and material evidence regarding the severity of the Veteran's Parkinson's disease was received. In a December 2012 rating decision, the AOJ readjudicated the Veteran's initial rating and pursuant to the M21-1, Part III.iv.4.G.25 granted separate compensable ratings for tremors and bradykinesia of the left upper extremity, bradykinesia of the right and left lower extremities, balance impairment (noncompensable), speech changes, loss of sense of smell (noncompensable), stooped posture (noncompensable), and loss of automatic movements (noncompensable), effective March 16, 2011. The Veteran timely appealed the effective dates assigned in the December 2012 rating decision for the grant of "service connection" for his Parkinson's residuals. The Board notes that under 38 C.F.R. § 3.156 (b) (2016), new and material evidence received prior to the expiration of the appeal period must be considered as having been filed in connection with the claim, which was pending at the beginning of the appeal period. Accordingly, the new and material evidence received within one year of the March 2011 rating decision prevented that decision, which assigned the Veteran's initial rating, from becoming final. See 38 C.F.R. § 3.156 (b) (20156) (stating that if new and material evidence is received within the relevant appeal period, the evidence is to be considered as having been filed in connection with the pending claim). See also Bond v. Shinseki, 659 F.3d 1362, 1368 (Fed. Cir. 2011). Accordingly, while the AOJ and the Appellant characterized the pending appeals as claims for earlier effective dates for service connection for the Veteran's various Parkinson's symptoms, service connection for Parkinson's and all identifiable residuals had already been granted in the March 2011 rating decision, effective October 15, 2001. Moreover, the initial rating assigned in the March 2011 rating decision had not become final. As such, in actuality, the Veteran was really appealing the initial rating assigned for Parkinson's disease, as it pertained when it became factually ascertainable that his Parkinson's residuals warranted separate ratings in excess of the minimum 30 percent rating under 38 C.F.R. § 4.124a, Diagnostic Code 8804 (2016). In light of 38 C.F.R. § 3.156 (b) (2016) and the procedural history discussed above, the Board re-characterized the matters on appeal as discussed above, and has, upon reflection, further clarified that issues 6 through 9 involve noncompensable ratings. The Board also observed that during the pendency of the appeal, a January 2014 rating decision granted the Veteran an earlier effective date of January 16, 2008, for a separate compensable rating for left upper extremity tremors and bradykinesia and granted earlier effective dates of October 21, 2009, for separate compensable ratings for bradykinesia right and left lower extremity with balance impairment, and separate noncompensable ratings for speech changes, loss of sense of smell, stooped posture, and loss of automatic movements. The Veteran was not granted an effective date retroactive to his initial grant of service connection, October 15, 2001, for any of his separate compensable Parkinson's residuals. As such, the benefits granted do not constitute a full grant of the benefits possible. Accordingly, these matters remain on appeal as noted by the Board in the remand. See AB v. Brown, 6 Vet. App. 35, 38 (1993). In January 2014, the RO also granted a total disability rating based on individual unemployability, effective September 2, 2008. Issues 10, 11 and 12 were remanded for issuance of an SOC pursuant to Manlincon v. West, 12 Vet. App. 238, 240-41 (1999). Such was issued; the appellant then perfected an appeal with these issues. As to issues 1 through 9, as sufficient efforts were made to obtain the noted medical records, the Board finds the directives have been substantially complied with, and the matter again is before the Board. Stegall v. West, 11 Vet. App. 268, 271 (1998). Appellant is now unrepresented in her appeal, as reflected in correspondence from her previous attorney dated in February 2017. FINDINGS OF FACT 1. With resolution of reasonable doubt, the manifestations of the Veteran's Parkinson's disease precluded employment, warranted a total disability rating based on individual unemployability (TDIU), and met the criteria for a single disability rated as 100 percent disabling with additional service connected disabilities independently ratable at 60 percent or more for purposes of housebound benefits. 2. The Veteran's diabetes mellitus was manifested by not more than the use of insulin and a restricted diet, or; oral hypoglycemic agent and restricted diet. There was no requirement for regulation of activities; there were no episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider; and either progressive loss of weight and strength or complications that would be compensable if separately evaluated was not shown. 3. The Veteran's dyskinesia, head and neck associated with Parkinson's was manifested by not more than convulsive tic; severe convulsive tic was not shown or approximated. 4. The Veteran's tremor and bradykinesia of the right upper extremity associated with Parkinson's disease, from January 16, 2008, was manifested by not more than moderate incomplete paralysis of the dominant side; severe incomplete or complete paralysis was not shown or approximated; prior to that date, the condition was of insufficient severity to warrant a compensable rating. 5. Prior to January 16, 2008, the date of a treatment record, the evidence weighs against a finding of increased severity for tremor and bradykinesia of the left upper extremity associated with Parkinson's such that a compensable rating was met or approximated. 6. Prior to January 16, 2008, the date of a treatment record, the evidence weighs against a finding of increased severity for dyskinesia, head and neck associated with Parkinson's such that a compensable rating was met or approximated. 7. Prior to October 21, 2009, the date of claim for service connection for Parkinson's disease, the evidence weighs against a finding of increased severity for tremors and bradykinesia of the right lower extremity such that a compensable rating was met or approximated. 8. Prior to October 21, 2009, the evidence weighs against a finding of increased severity for tremors and bradykinesia of the left lower extremity such that a compensable rating was met or approximated. 9. Prior to October 21, 2009, the evidence weighs against a finding that the criteria for a separate rating for speech changes, twelfth (hypoglossal) cranial nerve associated with Parkinson's were met. 10. Prior to October 21, 2009, the evidence weighs against a finding that the criteria for a separate rating for loss of automatic movements, fifth (trigeminal) cranial nerve associated with Parkinson's were met. 11. Prior to October 21, 2009, the evidence weighs against a finding that the criteria for a separate rating for loss of the sense of smell associated with Parkinson's were met. 12. Prior to October 21, 2009, the evidence weighs against a finding that the criteria for a separate rating for stooped posture, eleventh (spinal accessory, external branch cranial nerve) associated with Parkinson's were met. CONCLUSIONS OF LAW 1. The criteria for an award of special monthly compensation by reason of being housebound have been met. 38 U.S.C.A. § 1114 (West 2014); 38 C.F.R. § 3.350 (2016). 2. The criteria for a disability rating in excess of 20 percent for diabetes mellitus have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.119, Diagnostic Code 7913 (2016). 3. The criteria for a disability rating in excess of 10 percent for dyskinesia, head and neck associated with Parkinson's have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.124a, Diagnostic Code 8103 (2016). 4. The criteria for a disability rating in excess of 40 percent for tremor and bradykinesia of the right upper extremity associated with Parkinson's have not been met at any time; a compensable rating was not warranted prior to January 16, 2008. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.124a, Diagnostic Code 8004-8513 (2016). 5. The criteria for an effective date earlier than January 16, 2008, for the assignment of a separate compensable rating for tremor and bradykinesia of the left upper extremity associated with Parkinson's are not met. 38 U.S.C.A. §§ 5105, 5107, 5110 (West 2014); 38 C.F.R. §§ 3.151, 3.157, 3.400 (2016). 6. The criteria for an effective date earlier than January 16, 2008, for the assignment of a separate compensable rating for dyskinesia, head and neck associated with Parkinson's are not met. 38 U.S.C.A. §§ 5105, 5107, 5110 (West 2014); 38 C.F.R. §§ 3.151, 3.157, 3.400 (2016). 7. The criteria for an effective date earlier than October 21, 2009, for the assignment of a separate compensable rating for tremors and bradykinesia of the right lower extremity are not met. 38 U.S.C.A. §§ 5105, 5107, 5110 (West 2014); 38 C.F.R. §§ 3.151, 3.157, 3.400 (2016). 8. The criteria for an effective date earlier than October 21, 2009, for the assignment of a separate compensable rating for tremors and bradykinesia of the left lower extremity are not met. 38 U.S.C.A. §§ 5105, 5107, 5110 (West 2014); 38 C.F.R. §§ 3.151, 3.157, 3.400 (2016). 9. The criteria for an effective date earlier than October 21, 2009, for the assignment of a separate rating for speech changes, twelfth (hypoglossal) cranial nerve associated with Parkinson's are not met. 38 U.S.C.A. §§ 5105, 5107, 5110 (West 2014); 38 C.F.R. §§ 3.151, 3.157, 3.400 (2016). 10. The criteria for an effective date earlier than October 21, 2009, for the assignment of a separate rating for loss of automatic movements, fifth (trigeminal) cranial nerve associated with Parkinson's are not met. 38 U.S.C.A. §§ 5105, 5107, 5110 (West 2014); 38 C.F.R. §§ 3.151, 3.157, 3.400 (2016). 11. The criteria for an effective date earlier than October 21, 2009, for the assignment of a separate rating for loss of sense of smell associated with Parkinson's are not met. 38 U.S.C.A. §§ 5105, 5107, 5110 (West 2014); 38 C.F.R. §§ 3.151, 3.157, 3.400 (2016). 12. The criteria for an effective date earlier than October 21, 2009, for the assignment of a separate rating for stooped posture, eleventh (spinal accessory, external branch cranial nerve) associated with Parkinson's are not met. 38 U.S.C.A. §§ 5105, 5107, 5110 (West 2014); 38 C.F.R. §§ 3.151, 3.157, 3.400 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Housebound Claim SMC is designed to provide a higher level of compensation to Veterans who, by reason of the singular or combined effects of service-connected disabilities, face challenges above and different than the loss of earning capacity the rating schedule is designed to evaluate. 38 C.F.R. §§ 3.350, 4.1. SMC by reason of being housebound may be awarded on either of two bases. Statutory housebound is granted when a Veteran has a single disability rated totally (100 percent) disabling and an additional disability or disabilities independently rated a combined 60 percent disabling. 38 U.S.C.A. § 1114 (s); 38 C.F.R. § 3.350(i). The total disability rating requirement may be met by a finding of a total disability rating based on individual unemployability (TDIU) where that award is based on one single condition; even though an award of TDIU allows consideration of multiple conditions as a single disability under 38 C.F.R. § 4.16 (a), entitlement to SMC does not allow such. Bradley v. Shinseki, 22 Vet.App. 280, 293 (2008) )(a TDIU rating can qualify as an element for compensation at the 38 U.S.C.A. § 1114 (s) rate, but only if the TDIU is based on a single disability); VAOGCPREC 66-91 (Aug. 15, 1991) (several separately ratable disabilities cannot be combined to achieve a single total rating in order to qualify for SMC). Factual housebound, the second basis for this level of SMC, also requires a single disability rated totally (100 percent) disabling, to include TDIU based on one condition. Additionally, the Veteran must demonstrate that his service-connected disabilities render him unable to leave the immediate premises of his home. 38 U.S.C.A. § 1114 (s); 38 C.F.R. § 3.350 (i); Bradley v. Peake, 22 Vet.App. 280 (2008). This does not mean a Veteran can never leave his house, only that he must generally stay within the immediate surroundings. Occasionally leaving for appointments is allowable, but generally the Veteran must "stick close to home." The Veteran contended, and appellant continues to contend, that he was unemployable due to Parkinson's disease alone for the period prior to his death relevant to this claim. For the following reasons, the Board finds the evidence at least evenly balanced for and against this theory, and grants the claim. Although the Veteran's combined disability rating is 100 percent, none of his service-connected disabilities were rated as 100 percent disabling independently. They consist of Parkinson's disease with tremor and bradykinesia right upper extremity rated 40 percent disabling; post traumatic stress disorder (PTSD) rated 30 percent disabling; tremor and bradykinesia left upper extremity associated with Parkinson's disease with tremor and bradykinesia right upper extremity rated 30 percent disabling; postoperative residuals left knee arthroplasty rated 30 percent disabling; Achilles tendonitis, right ankle rated 20 percent disabling; diabetes mellitus with erectile dysfunction rated 20 percent disabling; amputation, tip, left ring finger rated as 10 percent disabling; a left knee disability rated 10 percent disabling; tinnitus rated 10 percent disabling; dyskinesias, head and neck due to Parkinson's rated 10 percent disabling; bradykinesia right and left lower extremity with balance impairment associated with Parkinson's disease with tremor and bradykinesia right upper extremity due to Parkinson's each rated 10 percent disabling and, multiple noncompensable disabilities to include left ear hearing loss, chest scar, Parkinson's related loss of sense of smell, loss of automatic movements fifth cranial nerve, stooped posture (external branch cranial nerve) and speech changes (twelfth cranial nerve). The Veteran was found to meet the requirements of TDIU in a January 2014 rating decision, effective from September 2, 2008. The RO went on to deny SMC based on housebound in that rating decision, as it noted that the VA examination on which it based the grant of TDIU (dated in November 2012) showed he was not be able to secure and maintain substantially gainful employment primarily due to Parkinson's. However, the examiner also listed other service connected disabilities which would only minimally cause employment issues, but coupled with Parkinson's, would also make employment opportunities difficult. Thus, the RO denied the claim because it found that the Veteran did not meet TDIU solely due to Parkinson's related conditions. Nonetheless, on review of the record, the Board finds that the Veteran's disability of Parkinson's disease alone did indeed support TDIU. While the November 2012 examination did in fact mention other conditions, a logical reading of the examination report, in the context of the entirety of the record relevant to this housebound claim, compels the conclusion that Parkinson's symptoms are what actually caused the Veteran to be unemployable and thus entitled to TDIU. While the other non-Parkinson's conditions certainly could impact employment, the record is replete with reference to the fact that the Veteran's altered gait, tremors and speech problems alone, all due to Parkinson's, were the factual cause of unemployability. It is noted in the record that he got through working due to tremors and walking difficulty related to Parkinson's. It was noted on 2012 examination that the Veteran had difficulty with voice quality making phone work difficult and could not adequately perform either physical or sedentary work due to tremors and balance issues with Parkinson's. Thus, the Board resolves reasonable doubt in the Veteran's favor and finds that the requirements for SMC under 38 U.S.C.A. § 1114 (s) (housebound status) were met for the time period relevant to the appeal when the Veteran was awarded a TDIU based on Parkinson's disease manifestations alone with additional service-connected disabilities independently rated at 60 percent or more. II. Veterans Claims Assistance Act of 2000 The requirements of 38 U.S.C.A. §§ 5103 and 5103A have been met as to the other claims. There is no issue as to providing an appropriate application form or completeness of the application. VA notified the Veteran/appellant in various letters throughout this appeal of the information and evidence needed to substantiate and complete the "downstream" claims decided here. Dingess v. Nicholson, 19 Vet. App. 473 (2006). With regard to the duty to assist, the Veteran's medical records, to include service treatment records (STRs), Social Security Administration records and VA records, have been obtained. Moreover, the Veteran underwent VA examinations prior to his death during the appeal period, reports and opinions of which adequately address the issues decided here. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Pursuant to the 2016 Board remand, records were sought from Gashland Clinic; a response that no records were available was received and communicated to appellant. VA has no further duty in regards to these records. The Board thus finds that further action is unnecessary under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159. The appellant will not be prejudiced as a result of the Board's adjudication of the claims below. III. The Claims for Higher Ratings Service connection and a 20 percent rating were awarded for diabetes mellitus in an October 2012 rating decision, and the Veteran disagreed with the assigned rating. The disability was later characterized on rating code sheets as diabetes mellitus type II with erectile dysfunction (ED). Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes (DCs). 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt will be granted to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on the merits, the preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). A veteran's entire history is reviewed when making a disability determination. See 38 C.F.R. § 4.1 (2016). But where service connection has already been established, and increase in the disability rating is at issue, it is the present level of the disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). In such cases, when the factual findings show distinct time periods during which a claimant exhibits symptoms of the disability at issue and such symptoms warrant different evaluations, staged evaluations may also be assigned. Hart v. Mansfield, 21 Vet. App. 505 (2007). Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be staged. Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, the service-connected disabilities did not materially change and uniform evaluations are warranted. The claims will be addressed separately below. A. Diabetes The Veteran's diabetes has been rated as 20 percent disabling since October 13, 2011, under DC 7913 of 38 C.F.R. § 4.119. This DC authorizes compensable ratings of 10, 20, 40, 60, and 100 percent. As the Veteran's diabetes was rated as 20 percent disabling during the appeal period, the Board's inquiry will focus on whether a 40, 60, or 100 percent rating was warranted at any time associated with his claim. Under DC 7913, a 40 percent rating is warranted where treatment requires insulin, restricted diet, and regulation of activities. A 60 percent rating is warranted where treatment requires insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. A 100 percent rating is warranted when diabetes requires more than one daily injection of insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. 38 C.F.R. § 4.119, DC 7913. Under this provision, "regulation of activities" means "avoiding strenuous occupational and recreational activities." Camacho v. Nicholson, 21 Vet. App. 360, 363 (2007). Note (1) to DC 7913 provides that compensable complications of diabetes are to be separately evaluated unless they are part of the criteria used to support a 100 percent rating, and that noncompensable complications are considered part of the diabetic process under DC 7913. In this case, the Veteran was not separately rated for ED as this was noncompensable and combined with the diabetes rating. The relevant evidence in this matter consists of a November 2012 VA examination report, treatment records, and the Veteran's lay assertions. This evidence does not approximate the criteria for a higher rating - i.e., the evidence did not indicate treatment requiring regulation of activities, nor did it indicate that diabetes caused episodes of ketoacidosis or hypoglycemic reactions requiring hospitalization or the requisite number of visits to a diabetic care provider along with the other criteria necessary. VA treatment reports show the Veteran used Metformin as treatment for diabetes. These records do not show his diabetes required regulation, of activities. There is also no evidence of hypoglycemia, diabetic ketoacidosis or hospitalization because of diabetes in the treatment record. VA examination in November 2012 revealed in relevant part that the Veteran used a prescribed oral hypoglycemic agent to control blood sugar. He did not require regulation of activities and there were no reported episodes of hypoglycemia or diabetic ketoacidosis. There was also no evidence of progressive unintentional weight loss. A review of the VA treatment records reflects that they are not inconsistent with the findings and facts noted in the above VA examination report. The appellant contends in general that the Veteran's diabetes warranted a higher rating. Here, the Board finds that the criteria for a rating in excess of 20 percent for diabetes are not met or approximated. There is no report or treatment record establishing that the Veteran's diabetes required insulin or regulation of activities, or that episodes of ketoacidosis or hypoglycemic reactions required hospitalization with the frequency at DC 7913 or weekly visits to a diabetic care. The record also shows there was neither related progressive loss of weight nor strength, and ED has not been shown to have been compensable if separately evaluated. In this regard, the Board notes that no information in the record suggest that the disorder ever became compensable. In assessing the claim, the Board has considered the Veteran's lay assertions and those of his wife. The Veteran was certainly competent to attest to the severity of observable symptoms he experienced from diabetes. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). However, he did not require insulin, and the objective evidence, prepared by skilled professionals, is far more probative and more credible than the lay statements regarding what treatment the Veteran underwent for his diabetes. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). And the medical evidence did not establish that the Veteran required insulin, a restricted diet, and regulation of activities, or that any other criteria are present in this claim. See Camacho, 21 Vet. App. at 364 (medical evidence is required to support a finding that regulation of activities is necessary to control diabetes). The most probative evidence establishes that the criteria for a 40 percent rating are not met or approximated. The Board finds the opinion of the 2012 VA examiner, who reviewed the record, to be the most probative evidence as to the actual manifestations of diabetes. As noted in Camacho, the determination is whether regulation of activities is medically necessary. In sum, the preponderance of the evidence is against the assignment of a rating in excess of 20 percent for diabetes at all times relevant to this decision. 38 U.S.C.A. § 5107 (b); 38 C.F.R. § 3.102. B. Dyskinesia, head and neck In a March 2011 rating decision, the RO granted service connection (Nehmer grant) and assigned a 30 percent evaluation for Parkinson's disease under DC 8004, effective October 15, 2001. This is the minimum evaluation for Parkinson's disease and included symptoms of tremors in all extremities with bradykinesia, rigidity, hypokinetic dysarthria and micrographia. Relevant to the instant appeal, a December 2012 rating decision assigned separate evaluations for the symptoms of Parkinson's disease. This included a 10 percent evaluation for balance impairment (ninth glossopharyngeal cranial nerve) under diagnostic code 8209. Following a review showing that this evaluation was based on dyskinesia of the head and neck and had been incorrectly identified as balance impairment, a rating decision of January 2014, corrected the aforementioned error and assigned a 10 percent evaluation for dyskinesia of the head and neck under diagnostic code 8103. The RO noted that the balance impairment was evaluated in the bradykinesia of the lower extremities as these disabilities were closely intertwined. Under DC 8103 of 38 C.F.R. § 4.124a, for neurological conditions and convulsive disorders, a convulsive tic is rated 30 percent if severe, 10 percent if moderate and noncompensable if mild. Note: Depending upon frequency, severity, muscle groups involved. Id. VA treatment records show mild dyskinesia of the head and neck, with worsening symptoms from January 2008. A report of VA examination in November 2012 reflects the Veteran had a tilt of the torso to the left with compensating torticollis to the right and moderate anterocollis. VA treatment records show there was some increase in head movements due to medication. These reflect that, although the Veteran's medication was adjusted with some improvement, he continued to manifest mild to moderate dyskinesia of the head and neck. However, a July 2010 consult also reflects that a deep brain stimulator place in May 2010 to address worsening symptoms significantly reduced his extremity tremors and head/neck dyskinesia. Here, the Board finds that the criteria for a rating in excess of 10 percent for dyskinesia, head and neck are not met or approximated. There is no report or treatment record establishing that the Veteran's dyskinesia, head and neck was severe. In assessing the claim, the Board has again considered the Veteran's lay assertions and those of the appellant. The Veteran was certainly competent to attest to the severity of observable symptoms he experienced. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). However, the objective evidence, prepared by skilled professionals, is far more probative and more credible than the lay statements regarding the manifestations of this complex disease. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). And the medical evidence did not establish that the dyskinesia, head and neck was severe. The most probative evidence establishes that the criteria for an increased rating are not met or approximated. The Board finds the opinion of the 2012 VA examiner, who reviewed the record, supports this finding and is highly probative evidence as to the actual manifestations of the condition, when viewed in the context of the treatment record. In sum, the preponderance of the evidence is against the assignment of a rating in excess of 10 percent for dyskinesia, head and neck at all times relevant to this decision. 38 U.S.C.A. § 5107 (b); 38 C.F.R. § 3.102. C. Tremor and bradykinesia of the right upper extremity As noted above, the minimum 30 percent evaluation for Parkinson's disease under DC 8004 was assigned in a March 2011 rating decision, and a December 2012 rating decision on appeal assigned separate evaluations for the symptoms of Parkinson's disease. This included a 40 percent evaluation for tremor and bradykinesia of the right upper extremity under diagnostic code 8513. While the rating decision code sheets reflect that the condition is rated under DC 8004-8513 as 30 percent from October 15, 2001, and as 40 percent from January 16, 2008, this reflects the minimum rating noted above prior to January 16, 2008. The Veteran was right handed as established in the record. Under DC 8103 of 38 C.F.R. § 4.124a, for diseases of the peripheral nerves, incomplete paralysis of a radicular nerve of the major arm is rated 20 percent if mild, 40 percent if moderate and 70 percent if severe. Complete paralysis is rated 90 percent. Id. The Board initially states that, prior to January 16, 2008, the evidence does not demonstrate that the right upper extremity condition warranted a separate rating. Manifestations in the treatment record were minimal. It is uncontroverted in the medical record that the first support for a separate compensable rating for this Parkinson's symptom was in January 16, 2008, VA treatment notes. These are later supported in the VA examination in November 2012. These notes show tremors in the upper extremities. The tremors were noted to fluctuate over time to the point that breakthrough symptoms occurred due to the effects of medication wearing off before the next scheduled dose. These records note the deep brain stimulator implanted, which produced some improvement, in May 2010 due to worsening symptoms. There is no finding that the right upper extremity incomplete paralysis was severe. Here, the Board finds that the criteria for a rating in excess of 40 percent for the right upper extremity are not met or approximated. In assessing the claim, the Board has again considered the Veteran's lay assertions and those of the appellant. Again, the objective evidence, prepared by skilled professionals, is far more probative and more credible than the lay statements regarding the manifestations of this complex disease. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). And the medical evidence did not establish that the right upper extremity tremors were severe. The most probative evidence establishes that the criteria for an increased rating are not met or approximated. The Board finds the opinion of the 2012 VA examiner, who reviewed the record, supports this finding and is highly probative evidence as to the actual manifestations of the condition, when viewed in the context of the treatment record. In sum, the preponderance of the evidence is against the assignment of a rating in excess of 40 percent for tremor and bradykinesia of the right upper extremity at all times relevant to this decision. 38 U.S.C.A. § 5107 (b); 38 C.F.R. § 3.102. IV. Effective Dates A. Tremor and bradykinesia of the left upper extremity and a 10 percent rating for dyskinesia, head and neck The Veteran seeks an effective date earlier than January 16, 2008, for the award of a compensable rating for these disabilities. A 30 percent evaluation is assigned for tremor and bradykinesia of the left upper extremity and a 10 percent rating for dyskinesia, head and neck. However, as explained herein, increase in severity approximating compensable ratings was not shown until a VA treatment record of that date, and there is no factually ascertainable evidence of a compensable level of disability prior to January 16, 2008. Generally, the effective date of an evaluation and award of pension, compensation or dependency and indemnity compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 U.S.C.A. § 5110 (a); 38 C.F.R. § 3.400. If, however, it is factually ascertainable that an increase in disability had occurred within the one year immediately preceding the date of receipt of the claim, then the Veteran can receive this earlier effective date. 38 U.S.C.A. § 5110 (b)(2); 38 C.F.R. § 3.400 (o)(2). Under applicable laws and regulations, if an increase in disability occurred within one year prior to the claim, the increase is effective as of the date the increase was "factually ascertainable." If the increase occurred more than one year prior to the claim, the increase is effective the date of claim. If the increase occurred after the date of claim, the effective date is the date of increase. 38 U.S.C.A. 5110 (b)(2) (West 2014); Harper v. Brown, 10 Vet. App. 125 (1997); 38 C.F.R. 3.400 (o)(1)(2) (2014); VAOPGCPREC 12-98 (1998). In making this determination, the Board must consider all of the evidence, including that received prior to previous final decisions. Hazan v. Gober, 10 Vet App 511 (1997). Under the provisions of 38 C.F.R. § 3.157 (b)(1), the date of outpatient or hospital examination or date of admission to a VA or uniformed services hospital will be accepted as the date of receipt of a claim. The provisions of this regulation apply only when such reports relate to examination or treatment of a disability for which service connection has previously been established or when a claim specifying the benefit sought is received within one year from the date of such examination, treatment or hospital admission. The Veteran disagreed with the December 2012 rating decision granting the above ratings for the left upper extremity and dyskinesias head/neck, to include the effective dates assigned. January 16, 2008, was the effective date eventually assigned for the rating for dyskinesias head/neck. As noted above, dyskinesias head/neck is rated under DC 8103, which provides a 10 percent rating if there is convulsive tic that is moderate and noncompensable if mild. Mild dyskinesia of the head and neck were noted in VA treatment records, with documented with worsening symptoms from January 16, 2008. VA treatment records show there was some increase in head movements due to medication not prior to that date. These reflect that, although the Veteran's medication was adjusted with some improvement, he continued to manifest mild to moderate dyskinesia of the head and neck. VA examination dated in November 2012 confirmed increased manifestations with a finding of tilt of the torso to the left with compensating torticollis to the right and moderate anterocollis. Here, it is first factually ascertainable that the Veteran meets the criteria for a 10 percent rating, based on moderate convulsive tic, not prior to January 16, 2008. No earlier treatment records document that the criteria were met. Accordingly, the proper effective date for the award of a separate 10 percent rating for the dyskinesia of the head and neck is the date of it was factually ascertainable, January 16, 2008. There is no legal basis for an effective date earlier than January 16, 2008. As with the right arm, tremor and bradykinesia of the left upper extremity is also rated under diagnostic code 8513, outlined above, with the exception that the left arm was the Veteran's minor arm. Under DC 8103 of 38 C.F.R. § 4.124a, for diseases of the peripheral nerves, incomplete paralysis of a radicular nerve of the minor arm is rated 20 percent if mild, 30 percent if moderate and 60 percent if severe. Complete paralysis is rated 80 percent. Id. It is uncontroverted in the record that the first medical support for evaluating the Parkinson's symptoms separately is the January 16, 2008, VA treatment note discussed in relation to the right arm. The findings are supported in the VA examination in November 2012. The records note tremors in the upper extremities which fluctuated over time to the point that breakthrough symptoms occurred due to the effects of medication wearing off before the next scheduled dose. Again, these records note the deep brain stimulator implanted in May 2010 due to worsening symptoms, but noted that this improved the functioning in the extremities to some extent. Here, it is first factually ascertainable that the Veteran meets the criteria for 30 percent rating for moderate incomplete paralysis in the right upper extremity as of, and not prior to, January 16, 2008. No prior treatment records suggest that the criteria were met, nor were the criteria for a compensable rating at all met. The record during that time was devoid of any suggestion of even mild incomplete paralysis. Accordingly, the proper effective date for the award of 30 percent for tremor and bradykinesia of the left upper extremity is the date these were factually ascertainable, January 16, 2008. There is no legal basis for an effective date earlier than January 16, 2008, for a compensable rating. B. Bradykinesia right and left lower extremities with balance impairment The Veteran seeks an effective date earlier than October 21, 2009, for the award of 10 percent ratings for bradykinesia right and left lower extremities with balance impairment. However, as explained herein, the date of claim for service connection for Parkinson's is October 21, 2009, and there are no manifestations of compensable bradykinesia right and left lower extremities prior to that date, and as such an increased rating prior to that date is not shown. The rating decision, dated in December 2012 granted service connection and 10 percent ratings for bradykinesias, lower extremities, under DC 8520, and a December 2013 SOC assigned the October 21, 2009, effective dates. DC 8520 provides for a 10 percent rating with mild incomplete paralysis of the sciatic nerve. The Board accepts that the claim for these conditions has been, in essence, open since October 21, 2009. The medical evidence suggests that bradykinesias, lower extremities, had been present since the date of claim as a manifestation of Parkinson's. As such, the separate 10 percent rating for each lower extremity is warranted effective October 21, 2009, but not prior thereto. There is no evidence of mild sciatic nerve paralysis in either the right or left lower extremity, required for a compensable rating, prior to the date of claim for service connection, October 21, 2009. The record is wholly devoid of any such findings. There is no legal basis for an effective date earlier than October 21, 2009. C. Speech changes, twelfth (hypoglossal) cranial nerve, loss of automatic movements, fifth (trigeminal) cranial nerve, loss of the sense of smell, stooped posture, eleventh (spinal accessory, external branch cranial nerve) The Veteran seeks an effective date earlier than October 21, 2009, for the award of separate ratings for speech changes, twelfth (hypoglossal) cranial nerve, loss of automatic movements, fifth (trigeminal) cranial nerve, loss of the sense of smell, and stooped posture, eleventh (spinal accessory, external branch cranial nerve) associated with Parkinson's. However, as explained herein, the date of claim for service connection for Parkinson's is October 21, 2009, and there is no support in the documented record for an effective date prior to the date of claim of service connection for Parkinson's for these separately-rated noncompensable disabilities. The rating decision, dated in December 2012 granted service connection and separate noncompensable ratings for these four disabilities, at the same time that it found that multiple other manifestations of Parkinson's warranted compensable ratings during an evaluation of a TDIU claim. A December 2013 SOC assigned the October 21, 2009, effective dates. The Board accepts that the claim for these conditions has been, in essence, open since October 21, 2009. The medical evidence suggests that speech changes, loss of automatic movements, loss of the sense of smell and stooped posture had been present, but not at compensable levels, since the date of claim as manifestations of Parkinson's. That is, since the October 21, 2009, date of claim, there was some evidence of symptomatology, but less than incomplete moderate fifth, eleventh and twelfth cranial nerve paralysis (DCs 8205, 8211, 8212), and less than complete loss of sense of smell (DC 6275) in the record. As such, the separate but noncompensable ratings for each condition are warranted effective October 21, 2009, but not prior thereto. There is no evidence of claims for or contentions related to these conditions prior to October 21, 2009. The record is wholly devoid of any relevant findings prior to October 21, 2009. There is no legal basis for an effective date earlier than October 21, 2009. ORDER Entitlement to SMC by reason of being housebound is granted. A rating in excess of 20 percent for diabetes mellitus, type II is denied. A rating in excess of 10 percent for dyskinesia, head and neck associated with Parkinson's is denied. An increased initial rating for tremor and bradykinesia of the right upper extremity associated with Parkinson's disease is denied; a rating in excess of 40 percent from January 16, 2008, is specifically denied. An effective date prior to January 16, 2008, for grant of a separate compensable rating for tremor and bradykinesia of the left upper extremity associated with Parkinson's is denied. An effective date prior to October 21, 2009, for grant of a separate compensable rating for tremor and bradykinesia of the right lower extremity with balance impairment associated with Parkinson's is denied. An effective date prior to October 21, 2009, for grant of a separate compensable rating for tremor and bradykinesia left lower extremity with balance impairment associated with Parkinson's is denied. An effective date prior to October 21, 2009, for grant of a separate rating for speech changes, twelfth (hypoglossal) cranial nerve associated with Parkinson's is denied. An effective date prior to October 21, 2009, for grant of a separate rating for loss of automatic movements, fifth (trigeminal) cranial nerve associated with Parkinson's is denied. An effective date prior to October 21, 2009, for grant of a separate rating for loss of the sense of smell associated with Parkinson's is denied. An effective date prior to October 21, 2009, for grant of a separate rating for stooped posture, eleventh (spinal accessory, external branch cranial nerve) associated with Parkinson's is denied. An effective date prior to January 16, 2008, for grant of a separate rating for dyskinesia, head and neck (previously rated as balance impairment associated with Parkinson's) is denied. ____________________________________________ J. W. FRANCIS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs